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MEDICAL INSURANCE

HMO Medical Plan
With the Anthem Blue Cross Health Maintenance Organization (HMO) plan, you must choose a Primary Care Physician (PCP) or
medical group within the “Select” network. All of your care must be directed through your PCP or medical group. Any specialty care
you need will be coordinated through your PCP and will generally require a referral or authorization. You will receive benefits only
if you use the doctors, clinics and hospitals that belong to the medical group in which you are enrolled, except in the case of an
emergency.

PPO Medical Plan
With the Anthem Blue Cross Preferred Provider Organization (PPO) plan, you have the freedom to choose your doctor without
using a Primary Care Physician (PCP) and you may self-refer to specialists. You may use a PPO provider whose negotiated rates
provide richer levels of benefits with claim forms filed by the providers. You may also obtain services using a non-network provider;
however, you will be responsible for the difference between the covered amount and the actual charges and you may be
responsible for filing claims.
ANTHEM BLUE CROSS ANTHEM BLUE CROSS
Plan Features SELECT NETWORK HMO PPO
Select Network Only Network Non-Network
Lifetime Maximum Unlimited Unlimited

Deductible (Annual)
- Individual $0 $500 $1,000
- Family $0 $1,500 $3,000
Co-Insurance (Plan Pays) 100% 80% after Deductible 60% after Deductible
Office Visit s
-Primary Care Physician $20 Copay $35 Copay 60% after Deductible
-Specialist $40 Copay
Out of Pocket Maximum
( Deductible Included)

- Individual $2,000 $4,500 $9,000
- Family $4,000 $9,000 $18,000
Hospitalization
- Inpatient $250/admit 80% after Deductible $500 Admit, then 60%
- Outpatient $125/visit 80% after Deductible 60% after Deductible
Emergency Services $100 Copay $150 Copay, then 80%
Ambulance Services $100 Copay $150 Copay, then 80%

Preventive Care 100% 100% Not Covered
Chiropractic Specialty Referral Required 80% 60% Max $25/Visit
Limited Benefits 24 Visits Maximum per Year

Mental Health & Substance Abuse
- Inpatient 100% $250 Admit, then 80% $500 Admit, then 60%
- Outpatient $20 Copay $20 60% after Deductible

Prescription Drugs - Copay
- Tier 1a / Tier 1b $5/$15 Copay $15 Copay $15 Copay + 50%
- Tier 2 $30 Copay $30 Copay $30 Copay + 50%
- Tier 3 $50 Copay $50 Copay $50 Copay + 50%
- Tier 4 30% up to $250 30% up to $250 Not Covered
- Mail Order (90 day supply) $12.50 /$37.50 / $90 / $150 $37.50 / $90 / $150 Not Covered

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